A structured care transitions program helps us interrupt the cycle of frequent readmissions for high risk patients. Through the use of liaison nurse visits, regular case reviews, data sharing and coordinated patient education, we improve the outcomes for discharged patients.

Clinical specialty programs in areas such as wound care, frailty, cardiac care and Parkinson’s disease help us meet the specialized needs of your sickest patients. We focus on patients with these serious illnesses and others, including COPD and diabetes, and use evidence based best practices, an advanced telehealth system and interdisciplinary teams to achieve better outcomes. We engage patients through the use of self-management support techniques, motivational interviewing, and health literacy best practices. Our VNA Community Healthcare & Hospice team focuses on relieving symptoms, reducing pain, alleviating stress and improving quality of life, which in addition to being in the best interest of the patient also reduces the need for repeated doctor’s office and ER visits.

Our robust data collection and visual analytics capabilities allow us to identify population characteristics and trends to analyze root causes of population health issues. We can provide demographic and outcome reports on patients you have referred to us.

In the community, we’ve organized a coalition of community agencies (Health Neighborhood) that provides health literacy education to community residents and works to improve communication across the continuum of care, from hospital to home. VNA Community Healthcare was the first home healthcare partner of the ABIM Foundation initiative Choosing Wisely, meant to educate consumers and providers about the necessity and value of medical tests and treatments.

Call Barbara Katz, RN, MSN, Director of Clinical Program Development or email BKatz@vna-commh.org. to see how we can share actionable data that improves outcomes.